What are the management options for inguinal hernia?

Management of Inguinal Hernia

Definitive Treatment Recommendation

Surgical repair with mesh is the definitive treatment for inguinal hernias, with laparoscopic approaches (TEP or TAPP) preferred when expertise is available due to superior outcomes in pain, recovery, and wound infection rates, while open Lichtenstein repair remains excellent when laparoscopic expertise is unavailable. 1, 2

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Initial Assessment and Urgency Stratification

Determine Clinical Presentation

Reducible hernia:

• Elective repair is recommended to prevent future complications 1
• Watchful waiting may be considered only in truly asymptomatic or minimally symptomatic patients, though 23-35% will eventually require surgery 3, 4
• Acute incarceration risk is low (1.8/1000 patient-years) but increases with delay 4

Incarcerated hernia (irreducible but no vascular compromise):

• Urgent surgical intervention required within 1-2 weeks 1, 2
• Use SIRS criteria, CT findings, elevated lactate, CPK, and D-dimer to predict strangulation 1, 2

Strangulated hernia (vascular compromise suspected):

• Emergency repair is mandatory immediately to prevent bowel necrosis and mortality 1, 2
• Delayed diagnosis beyond 24 hours significantly increases mortality 1, 2
• Signs include irreducibility, tenderness, erythema, systemic symptoms 5

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Surgical Approach Selection Algorithm

For Non-Complicated (Reducible) Hernias

Laparoscopic repair (TEP or TAPP) is preferred when:

• Surgeon expertise is available 1, 6
• Bilateral hernias present (allows simultaneous repair and detection of occult contralateral hernias in 11.2-50% of cases) 1, 2
• Patient desires faster return to activities 1
• Benefits include: reduced postoperative pain, lower analgesic requirements, lower wound infection rates (P<0.018), and comparable recurrence rates to open repair 1

Open Lichtenstein repair is preferred when:

• Laparoscopic expertise unavailable 2, 6
• Significant patient comorbidities present 1
• Local anesthesia desired or general anesthesia contraindicated 1, 2
• Patient preference or cost considerations 7, 8

For Emergency/Complicated Hernias

Incarcerated without strangulation:

• Laparoscopic approach (TAPP or TEP) is appropriate when no bowel necrosis suspected 1
• Hernioscopy (laparoscopy through hernia sac) can assess bowel viability, avoiding unnecessary laparotomy and decreasing hospital stay 1, 2
• Local anesthesia can be used for open repair in absence of bowel gangrene 1, 2

Strangulated or suspected bowel compromise:

• Open preperitoneal approach is preferable when bowel resection may be needed 1
• General anesthesia is required when bowel gangrene suspected or peritonitis present 1
• Diagnostic laparoscopy can assess bowel viability after spontaneous reduction 1, 2

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Mesh Selection Based on Surgical Field

Clean Field (CDC Class I)

• Prosthetic repair with synthetic mesh is strongly recommended (Grade 1A) 1
• Synthetic mesh shows significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk 1
• Standard polypropylene mesh remains the choice, though lightweight meshes may offer advantages 8

Clean-Contaminated Field (CDC Class II-III)

• Emergent prosthetic repair with synthetic mesh can be performed even with intestinal strangulation and/or bowel resection without gross enteric spillage 1
• Associated with significantly lower recurrence risk regardless of defect size 1
• 48-hour antimicrobial prophylaxis recommended 1, 2

Contaminated Field (CDC Class IV - with bowel necrosis or peritonitis)

• For small defects (<3 cm): primary repair recommended 1
• When direct suture not feasible: biological mesh may be used 1
• If biological mesh unavailable: polyglactin mesh repair or open wound management with delayed repair 1
• Full antimicrobial therapy required 1, 2

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Special Populations

Pediatric/Infant Hernias

• All inguinal hernias in infants require surgical repair to prevent bowel incarceration and gonadal infarction/atrophy 2, 5
• Urgent surgical referral within 1-2 weeks of diagnosis 5
• Examine both groins bilaterally as contralateral patent processus vaginalis occurs in 64% of infants younger than 2 months 5
• Preterm infants require repair soon after diagnosis despite higher surgical complication rates 5
• Postoperative apnea monitoring for 12 hours required in infants under 46 weeks corrected gestational age 5

Bilateral Hernias

• Laparoscopic approach strongly preferred to address both sides simultaneously and detect occult contralateral hernias 1, 2

Recurrent Hernias

• TAPP may be easier than TEP in recurrent cases 1
• Requires tailored approach based on previous repair type 6

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Critical Pitfalls to Avoid

Delaying repair of strangulated hernias:

• Leads to bowel necrosis, increased morbidity, and significantly higher mortality 1, 2
• Diagnosis delay beyond 24 hours dramatically worsens outcomes 1, 2

Overlooking contralateral hernias:

• During TAPP, inspect contralateral side after patient consent (occult hernias present in 11.2-50% of cases) 1, 2
• Bilateral examination crucial in all patients 5

Inappropriate mesh use in contaminated fields:

• Avoid synthetic mesh with gross enteric spillage or peritonitis 1
• Use biological mesh or delayed repair in heavily contaminated fields 1

Missing femoral hernias:

• Higher risk of strangulation than inguinal hernias 5
• Examine femoral canal separately 5

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Postoperative Management

Antimicrobial prophylaxis:

• 48-hour prophylaxis for intestinal strangulation/bowel resection (CDC II-III) 1, 2
• Full antimicrobial therapy for peritonitis (CDC IV) 1, 2

Monitor for complications:

• Wound infection (lower with laparoscopic approach) 1, 5
• Chronic pain (occurs in 10-12% of patients) 6, 3
• Recurrence (11% overall rate) 6
• Testicular complications in males (atrophy, vas deferens injury) 1, 5

Activity restrictions:

• Laparoscopic patients return to normal activities more quickly 1, 7
• Avoid activities increasing intra-abdominal pressure initially 5